GI content in ET tube

I have a question...I am a new NICU nurse and have been off orientation about 1 month. Tonight was my first night taking care of an intubated baby on my own and I already feel like I've done something wrong. The baby was a 26 weeker, intubated with a large air leak due to tracheal malasia. I was told he had been dingy on his monitor and was very positional and they increased his vent supprt that day and he was doing much better (was bagged 3x the previous day). Also I was told his abdominal circumference increased 1.5 cm on dayshift, no aspirates or spit ups and they have him a glycerin chipped and he pooped and circumference went back down and was stable. I had no issues from him until about 9p when he started desating at rest...I did oral suction with small amount of clear secretions and he was still desating and HR was dropping so I suctioned his ET tube and got moderate secretions. His sats and Hr increased a little but went back down. I stimulated him, increased his Fio2 and he was having color changes. I bagged him and I suctioned again and large amounts of his feeding came up. I called rapid response, they took over..extubated and reintubated but advanced ET tube .5 cm. all was good...no aspirates, no desats, continued his free dings. Then at 0030 same thing...desats, suctioned and this time I didn't even have a chance to bag him before his feeding was noted in the tube. They deep suctioned and feeding was coming out of his mouth and nose. He was extubated, reintubated and advanced the ET tube another .5 and made him NPO. We later withdrew tube .5 cm because it was in too far. Then the rest of his night was fine. I was able to wean his fio2, no aspirates, no change in abdominal circ. started fluids, etc. but my question is why?? Why was the feeding coming through his et tube?? Did I pull the tube out?? I checked placement and it appeared in place...the tube was cuffless..his air leak was audible. The MD talked to me and I explained the only recent changes were they introduced multi vits and changed his feeding to half breast milk and half formula..he thinks maybe it was an osmalarity issue and decided to hold the multi vit. But I can't help but wonder if I did something wrong?? I checked OG placement each time and checked for aspirate..I even advanced the OG 1 cm. I don't think the OG was misplaced because the MD did an X-ray and said it was fine. He also said belly looked good on the X-ray. Was it reflux? Did I extubate on accident?? I just need some peace of mind..I feel like I did all I can do but being a new nurse I wonder if I missed something. Any advice? Please be kind..I'm obviously shaken up a little.

I've never done peds or neonatal in my life, just adult ICU... I have to say you NICU nurses are hardcore. Thanks for what you do. Sounds like you care and did everything right and just had a very sick patient. Sometimes despite out best efforts things go wrong. Thank you for wanting to improve yourself as a healthcare professional and for taking care of such little humans.

Sep 25, '13

I'm guessing the kid refluxed and - because of the uncuffed tube and air leak- aspirated. Nothing you did, just happens sometimes.

Sep 25, '13

Sounds like major reflux. Is he a previous 26 weeker or a newer kid? If he has tracheal malacia and continues to do this he may need a trach, GT and Nissan procedure to protect his airway. It sounds like you did nothing wrong. Junior needs an upper GI to see what is going on if he is refluxing that badly. But he is going to end up with pneumonia if he keeps doing that!

Hang in there!!!

Sep 25, '13

I agree w/NicuGal. Can't help but wonder if he has a TEF? Something's going on. Is he on meds for reflux? Not enough pieces of the puzzle here...

Best wishes. I don't think it's anything you've done, tho.

Sep 25, '13

I thought that too, TEF.

Sep 25, '13

Well he WAS a 26 weeker, now about 28 weeks and has had no feeding issues this far. So I don't think TEF. Not on any reflux meds at the moment but this was his first episode of feeding intolerance to my knowledge. I assumed the air leak could be to blame along with the tracheal malasia but giving report to his primary nurse this AM she almost acted ****** that he was NPO by making comments about the OG being in far enough and almost inadvertently implied that I did something. So of course I went home and cried thinking I made some horrible mistake not once, but twice. Thank you for the support! I hope they find out what is wrong with the kiddo.

Sep 25, '13

This is jmo, but 1 mo of orientation, 1st time w/a baby this complex, I just think is a bit much. Did you have an assigned resource nurse? The primary can think whatever she wants, but these babies reserve the right to not tolerate feedings any time they want. And they often DON'T tolerate their feedings, develop reflux, and generally act like what they are.

I'm not in active practice anymore, but I've got ~ 30 yrs of experience in NICU. This little one is giving us the "don't trust me" attitude! Let's hope he gets better. Don't let the primary scare you, 'k?

Sep 25, '13

Are you certain it was formula, and not chyle or a pleural effusion seeping around the uncuffed tube? I also considered reflux (most likely) and aspiration.

Sep 26, '13

Oh no, I had 12 weeks of orientation...I have been off orientation for a month. Which imo that assignment was still a little much considering prior to this night I was taking 3:1 feeder growers. Haven't even bagged a baby before that night! And sadly no, no resource nurse either. My nursery roommate was a brand new nurse who had been off orientation for only 2 weeks so basically no experience between the two of us. Thank goodness for experienced nurses across the hall. I've never been happier to see those familiar faces than when they came to help me.

And no, I guess I'm not sure it was formula but he was a q2 feeder and both "events" occurred 45mins-1 hour after a feeding. It looked like formula...so I'm assuming that was what it was. I thought his air leak was the cause...which according to the vent could be as high as 90% based on his position.. The MD and other nurses said possibly bad reflux...I was content with that answer but the dayshift nurse, like I said, made me doubt myself and kind of gave me the impression that I did something wrong. I honestly cried a few relief tears to your alls responses of reflux or something that was beyond my control.